The historical standard of treatment for all thyroid cancer was total thyroidectomy followed by radioactive iodine ablation. Today, surgery remains the standard of care for most thyroid cancers and nodules suspicious for cancer. However, surgical options have shifted from the one-size-fits-all approach of total thyroidectomy. Considering the prevalence of well-differentiated thyroid cancer, guidelines and practice recommendations support less extensive surgery in patients with small, low-risk differentiated cancers. In the setting of expanded treatment options for low-risk disease, decision making for surgical intervention has become increasingly complex. Disease-related factors, including extent of disease and type of thyroid cancer, as well as patient-related clinical factors play a significant role in surgical decision making. When considering the extent of index thyroidectomy, surgeons must tailor their decision making to balance the treatment of cancer with patient preferences and the potential harms of overtreatment. In this chapter, we will review the salient disease- and patient-related factors as well as a decision-making framework to consider when evaluating a patient with thyroid cancer for surgical intervention.